2017 IPS Parish Health & Pastoral Care Certificate

PROGRAM REGISTRATION

This program will be held on October 22-27, 2017 at the LUREC (Loyola University Retreat and Ecology Campus) in Woodstock, Illinois--about 50 miles northwest of Chicago.

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* 1. First Name:

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* 2. Last Name:

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* 3. How would you like your name to appear on your certificate?

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* 4. Contact Information:

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code (ex. 12345) *

Country

Email Address *

Phone Number (000) 000-0000 *

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* 5. Emergency Contact:

Name

Phone Number (000) 000-0000

Relationship

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* 6. What Archdiocese or Diocese are you affiliated with?

If other (please specify)

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* 7. Your Affiliation:

Parish Name

Your Ministry Title

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* 8. What is your present ministry work?

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* 9. In 250-300 words, please provide a description of your present ministry work.

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* 10. What are your overall goals or aspirations?

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* 11. Would you like to assist with the liturgies and prayer services during the program?

Yes, I am ordained minister and would like to concelebrate

Yes, I would like to assist with Eucharistic Ministry

Yes, I am open to supporting the liturgies and prayer services in other ways

No, I am not interested in participating in the liturgies and prayer services

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* 12. Would you prefer your small group interaction be in:

English

Spanish

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* 13. Do you have any dietary restrictions? (Please select all that apply.)

I do not have any dietary restrictions

Vegetarian

Vegan

Diabetic

Lactose Free

Gluten Free

Food Allergy (e.g. peanut free, shellfish)

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* 14. Which of the following areas are of primary interest to you?

Active Listening and Human Relations Skills

Individual and Community Mental Health

Individual and Community Physical Health

Social Justice and Community Nonviolence

Domestic Violence Intervention

Active Accompaniment through Transitions Illness, Death, and Loss

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* 15. For networking purposes, we encourage you to submit a headshot picture of yourself.

Yes, I will submit my headshot photo to Mirta Garcia, mgarcia29@luc.edu before October 1, 2017.

No, I am not interested in submitting my photo.

2017 IPS Parish Health & Pastoral Care Certificate

PROGRAM REGISTRATION

Question Title

* 1. First Name:

Question Title

* 2. Last Name:

Question Title

* 3. How would you like your name to appear on your certificate?

Question Title

* 4. Contact Information:

Question Title

* 5. Emergency Contact:

Question Title

* 6. What Archdiocese or Diocese are you affiliated with?

Question Title

* 7. Your Affiliation:

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* 8. What is your present ministry work?

Question Title

* 9. In 250-300 words, please provide a description of your present ministry work.

Question Title

* 10. What are your overall goals or aspirations?

Question Title

* 11. Would you like to assist with the liturgies and prayer services during the program?

Question Title

* 12. Would you prefer your small group interaction be in:

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* 13. Do you have any dietary restrictions? (Please select all that apply.)

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* 14. Which of the following areas are of primary interest to you?

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* 15. For networking purposes, we encourage you to submit a headshot picture of yourself.

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* 16. Reminder: Your Case Study must be emailed to Mirta Garcia, mgarcia29@luc.edu before October 1, 2017

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* 17. Do you have any specific needs requiring accommodations?